Chapter 6: Corticosteroids: Indications, Pharmacology, and Risks in Interventional Pain Management

INTRODUCTION

Corticosteroids have been a mainstay in the area of interventional pain management because of their clinical effectiveness in treating numerous inflammatory subacute and chronic pain conditions. These conditions often include significant inflammatory components as seen in certain neuraxial, intra-articular and extra-articular disorders.

INDICATIONS FOR CORTICOSTEROIDS IN INTERVENTIONAL PAIN MANAGEMENT

Hollander introduced the concept that injected corticosteroids can have a positive effect on inflammatory pain conditions in 1950. Since Hollander’s study, the role of corticosteroids has expanded into treating many other types of acute and chronic pain conditions such as degenerative and inflammatory conditions of the peripheral joints and the spine.⁶

The common indications for corticosteroids in interventional pain medicine can be broadly divided into the following categories:

• Peripheral joints

• Extra-articular tissue (eg, bursa)

• Neuraxial structures and spaces (eg, facet joints, epidural space)

Epidural steroids were introduced into the United States in the 1960s and are the most commonly performed spinal interventions in the United States with an annual estimated Medicare spending of 175 million dollars in 2001. Studies have shown that epidural steroid can be effective in the treatment of painful radiculo­pathy from:

• Disc herniations

• Spondylolysis

• Spinal stenosis

• Annular tears

• Degenerative conditions of cervical and lumbar spine

Other diseases that may benefit from corticosteroid injections include:

• Osteoarthritis of the spine and peripheral joints

• Rheumatoid arthritis and extra-articular disorders

• Tendinitis

• Bursitis

• Ligament sprain

• Tenosynovitis

• Other overuse syndromes

CONTRAINDICATIONS FOR CORTICOSTEROIDS IN INTERVENTIONAL PAIN MANAGEMENT

The contraindications are more a function of the specific injection being performed rather than whether if cortisone should be included in the injectate. Active infection at the needle insertion site must be considered before all injections although this at times may prove difficult to differentiate from noninfectious arthropathies. Bleeding disorders are especially important in neuraxial procedures as they can lead to paralysis if the physician is not appropriately vigilant. The absolute and relative contraindications for corticosteroid injections are listed in Table 6-1.

PHYSIOLOGY

• Cortisol is an endogenous glucocorticoid required for normal cellular function synthesized in the zona fasciculata of the adrenal cortex.

• It is essential for normal metabolism, wound healing, gluconeogenesis, lipolysis, and immunologic activity.

• It has significant anti-inflammatory actions that are beneficial in the treatment of chronic pain conditions.

• Cortisol is under the control of the hypothalamic-pituitary-adrenal axis (HPA).

• In the presence of a stressor, the ...